Accurate Education – LBP: Failed Back Surgery

Failed Back Surgery Syndrome (FBSS) may be a consequence of both preoperative and postoperative risk factors. Clearly, all efforts should be made prior to surgery to assure the greatest likelihood of success, including addressing the risks for failure. However, for those suffering from FBSS, the understanding of postoperative variables may facilitate successful reduction of pain.

Preoperative factors

Many preoperative variables influence the likelihood of successful spinal surgery including the accuracy of diagnoses, socioeconomic, behavioral, and psychological factors. Understanding these variables may prepare one for greater likelihood of a successful surgery.

Accuracy of Diagnosis

While diagnostic accuracy is an obvious variable, inaccurate diagnosing is probably the major factor leading to FBSS. For example, it is estimated that as much as 58% of FBSS results from undiagnosed lateral stenosis of the lumbar spine (see Spinal Stenosis). As a patient, it would appear that the responsibility of accurate diagnosing lies with the surgeon. Superficially, this is true but on deeper inspection it becomes clear that the surgeon’s diagnosis is based largely on the information provided by the patient. It is well established that neither the physical examination nor findings on imaging studies such as x-rays, CT scans and MRIs necessarily correlate with the source or severity of perceived pain.

While the patient’s history and description of LBP is also not in of itself always reliable in establishing a diagnosis, the important thing to understand is that the patient’s experience and perspective of their pain is the most important factor that connects the diagnostice process all together. It can direct the physician to an accurated diagnosis or completely lead to the wrong diagnosis. The better a patient observes their own symptoms by paying attention to the variables that influence those symptoms and the better they can communicate these observations with the physician, the more likely an accurate diagnosis will be identified. This website has many links to pages that explore different sources of LBP, their causes and their distinguishing features. They can be a resource to provide insights for the patient to better observe and communicate their symptoms to the physician and potentially improve the physician’s diagnostic accuracy.

Because the basis of the decision to undergo surgery and the type of surgery to be performed are different for each patient, it is beyond the scope of this website to provide individualized guidance.  It may be helpful however to note that  certain diagnoses are associated with greater rates of FBSS. For example, multiple studies have shown that back pain caused by foraminal stenosis is associated with greater rates of FBSS than pain caused by recurrent disc herniation.

Myofascial Pain

The development of myofascial pain often accompanies and/or follows most if not all of the other common reasons for LBP including disc and facet pain. In fact, the presence of myofascial pain can be the dominant pain generator whose severity drives a patient to seek surgical solutions which would be destined not only to fail but to worsen pain. Because myofascial pain and its referral patterns often overlack or mimic referral patterns from discs and facets, myofascial pain is often overlooked as the pain generator and surgery is performed. A careful evauation for myofascial pain should always be assessed carefully and treated accordingly by a clinician knowedgeable about myofascial pain – most often not a surgeon. It is the opinion of many physicians that a great number of unsuccessful outcomes of surgery for LBP are a direct result of failing to identify and treat myofascial pain.

Because myofascial pain can also develop as a complication of lumbar surgery, the same caveat applies regarding the careful assessment and treatment this condition.

See Myofascial Pain

Depression

Depression is one of the strongest predictors of a negative outcome after spinal surgery. Depressed patients generally feel more pain and weakness postoperatively and are less likely to return to work than those without depression. Preoperative treatment of depression, anxiety, and other psychological conditions may be useful in the prevention of FBSS.

See Depression

Postoperative Factors

The recurrence of back pain or the failure of back pain to resolve can be due to many variables. Pain may result from further degeneration of the spine or new spine problems, or as a result of trauma or stress from adjacent muscles.

Biomechanical Changes

Back surgery commonly results in biomechanical changes in the area of surgery, resulting in an increased load burden in adjacent structures that can accelerate degenerative changes in the areas of the spine, both above and below the fusion. Fusion of the lumbar spine to the sacrum or fusion of multiple lumbar segments may lead to sacroiliac joint (SIJ) dysfunction. These biomechanical changes may also result in increased tension on the prevertebral and postvertebral muscles that control movement of the spinal column leading to myofascial pain, an extremely common source of pain in FBSS. Physical therapy, myofascial therapy, education and attention to posture and the mechanics of lifting, carrying etc. may reduce these changes and limit the development of postoperative pain.